Swine influenza

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Influenza (flu)

Swine influenza is endemic in pigs

Electron microscope image of the reassorted H1N1 influenza virus

photographed at the CDC Influenza Laboratory. The viruses are 80–
120 nanometres in diameter.
Swine influenza (also called swine flu, hog flu, pig flu and sometimes, the
swine) is an infection by any one of several types of swine influenza virus.
Swine influenza virus (SIV) is any strain of the influenza family of viruses
that is endemic in pigs.[2] As of 2009, the known SIV strains include
influenza C and the subtypes of influenza A known as H1N1, H1N2, H3N1,
H3N2, and H2N3.
Swine influenza virus is common throughout pig populations worldwide.
Transmission of the virus from pigs to humans is not common and does not
always lead to human influenza, often resulting only in the production of
antibodies in the blood. If transmission does cause human influenza, it is
called zoonotic swine flu. People with regular exposure to pigs are at
increased risk of swine flu infection. The meat of an infected animal poses
no risk of infection when properly cooked.
During the mid-20th century, identification of influenza subtypes became
possible, allowing accurate diagnosis of transmission to humans. Since then,
only 50 such transmissions have been confirmed. These strains of swine flu
rarely pass from human to human. Symptoms of zoonotic swine flu in
humans are similar to those of influenza and of influenza-like illness in
general, namely chills, fever, sore throat, muscle pains, severe headache,
coughing, weakness and general discomfort.
Classification
Of the three genera of influenza viruses that cause human flu, two also cause
influenza in pigs, with influenza A being common in pigs and influenza C
being rare. Influenza B has not been reported in pigs. Within influenza A
and influenza C, the strains found in pigs and humans are largely distinct,
although due to reassortment there have been transfers of genes among
strains crossing swine, avian, and human species boundaries.
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Influenza C
Influenza C viruses infect both humans and pigs, but do not infect birds.
Transmission between pigs and humans have occurred in the past. For
example, influenza C caused small outbreaks of a mild form of influenza
amongst children in Japan and California. Due to its limited host range and
the lack of genetic diversity in influenza C, this form of influenza does not
cause pandemics in humans.
Influenza A
Swine influenza is known to be caused by influenza A subtypes H1N1,
H1N2, H2N3, H3N1, and H3N2. In pigs, three influenza A virus subtypes
(H1N1, H1N2, and H3N2) are the most common strains worldwide. In the
United States, the H1N1 subtype was exclusively prevalent among swine
populations before 1998; however, since late August 1998, H3N2 subtypes
have been isolated from pigs. As of 2004, H3N2 virus isolates in US swine
and turkey stocks were triple reassortants, containing genes from human
(HA, NA, and PB1), swine (NS, NP, and M), and avian (PB2 and PA)
lineages.
Surveillance
Although there is no formal national surveillance system in the United States
to determine what viruses are circulating in pigs, there is an informal
surveillance network in the United States that is part of a world surveillance
network.
Veterinary medical pathologist, Tracey McNamara, set up a national disease
surveillance system in zoos because the zoos do active disease surveillance
and many of the exotic animals housed there have broad susceptibilities.
Many species fall below the radar of any federal agencies (including dogs,
cats, pet prairie dogs, zoo animals, and urban wildlife), even though they
may be important in the early detection of human disease outbreaks.

History
Swine influenza was first proposed to be a disease related to human
influenza during the 1918 flu pandemic, when pigs became sick at the same
time as humans. The first identification of an influenza virus as a cause of
disease in pigs occurred about ten years later, in 1930. For the following 60
years, swine influenza strains were almost exclusively H1N1. Then, between
1997 and 2002, new strains of three different subtypes and five different
genotypes emerged as causes of influenza among pigs in North America. In
1997–1998, H3N2 strains emerged. These strains, which include genes
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derived by reassortment from human, swine and avian viruses, have become
a major cause of swine influenza in North America. Reassortment between
H1N1 and H3N2 produced H1N2. In 1999 in Canada, a strain of H4N6
crossed the species barrier from birds to pigs, but was contained on a single
farm.
The H1N1 form of swine flu is one of the descendants of the strain that
caused the 1918 flu pandemic. As well as persisting in pigs, the descendants
of the 1918 virus have also circulated in humans through the 20th century,
contributing to the normal seasonal epidemics of influenza. However, direct
transmission from pigs to humans is rare, with only 12 cases in the U.S.
since 2005. Nevertheless, the retention of influenza strains in pigs after these
strains have disappeared from the human population might make pigs a
reservoir where influenza viruses could persist, later emerging to reinfect
humans once human immunity to these strains has waned.
Swine flu has been reported numerous times as a zoonosis in humans,
usually with limited distribution, rarely with a widespread distribution.
Outbreaks in swine are common and cause significant economic losses in
industry, primarily by causing stunting and extended time to market. For
example, this disease costs the British meat industry about £65 million every
year.
1918 pandemic in humans
The 1918 flu pandemic in humans was associated with H1N1 and influenza
appearing in pigs; this may reflect a zoonosis either from swine to humans,
or from humans to swine. Although it is not certain in which direction the
virus was transferred, some evidence suggests that, in this case, pigs caught
the disease from humans. For instance, swine influenza was only noted as a
new disease of pigs in 1918, after the first large outbreaks of influenza
amongst people. Although a recent phylogenetic analysis of more recent
strains of influenza in humans, birds, and swine suggests that the 1918
outbreak in humans followed a reassortment event within a mammal, the
exact origin of the 1918 strain remains elusive. It is estimated that anywhere
from 50 to 100 million people were killed worldwide.
1976 U.S. outbreak
On February 5, 1976, in the United States an army recruit at Fort Dix said he
felt tired and weak. He died the next day and four of his fellow soldiers were
later hospitalized. Two weeks after his death, health officials announced that
the cause of death was a new strain of swine flu. The strain, a variant of
H1N1, is known as A/New Jersey/1976 (H1N1). It was detected only from
January 19 to February 9 and did not spread beyond Fort Dix.

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This new strain appeared to be closely related to the strain involved in the
1918 flu pandemic. Moreover, the ensuing increased surveillance uncovered
another strain in circulation in the U.S.: A/Victoria/75 (H3N2) spread
simultaneously, also caused illness, and persisted until March. Alarmed
public-health officials decided action must be taken to head off another
major pandemic, and urged President Gerald Ford that every person in the
U.S. be vaccinated for the disease.
The vaccination program was plagued by delays and public relations
problems. On October 1, 1976, immunizations began and three senior
citizens died soon after receiving their injections. This resulted in a media
outcry that linked these deaths to the immunizations, despite the lack of any
proof that the vaccine was the cause. According to science writer Patrick Di
Justo, however, by the time the truth was known—that the deaths were not
proven to be related to the vaccine—it was too late. "The government had
long feared mass panic about swine flu—now they feared mass panic about
the swine flu vaccinations." This became a strong setback to the program.
There were reports of Guillain-Barré syndrome, a paralyzing neuromuscular
disorder, affecting some people who had received swine flu immunizations.
This syndrome is a rare side-effect of modern influenza vaccines, with an
incidence of about one case per million vaccinations. As a result, Di Justo
writes that "the public refused to trust a government-operated health
program that killed old people and crippled young people." In total,
48,161,019 Americans, or just over 22% of the population, had been
immunized by the time the National Influenza Immunization Program (NIIP)
was effectively halted on December 16, 1976.
Overall, there were 1098 cases of Guillain-Barré Syndrome (GBS) recorded
nationwide by CDC surveillance, 532 of which were linked to the NIIP
vaccination, resulting in death from severe pulmonary complications for 25
people, which, according to Dr. P. Haber, were probably caused by an
immunopathological reaction to the 1976 vaccine. Other influenza vaccines
have not been linked to GBS, though caution is advised for certain
individuals, particularly those with a history of GBS. Still, as observed by a
participant in the immunization program, the vaccine killed more Americans
than the disease did.
1988 zoonosis
In September 1988, a swine flu virus killed one woman and infected others.
32-year old Barbara Ann Wieners was eight months pregnant when she and
her husband, Ed, became ill after visiting the hog barn at a county fair in
Walworth County, Wisconsin. Barbara died eight days later, after
developing pneumonia. The only pathogen identified was an H1N1 strain of
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swine influenza virus. Doctors were able to induce labor and deliver a
healthy daughter before she died. Her husband recovered from his
symptoms.
Influenza-like illness (ILI) was reportedly widespread among the pigs
exhibited at the fair. 76% of 25 swine exhibitors aged 9 to 19 tested positive
for antibody to SIV, but no serious illnesses were detected among this group.
Additional studies suggested between one and three health care personnel
who had contact with the patient developed mild influenza-like illnesses
with antibody evidence of swine flu infection. However, there was no
community outbreak.
1998 US outbreak in swine
In 1998, swine flu was found in pigs in four U.S. states. Within a year, it had
spread through pig populations across the United States. Scientists found
that this virus had originated in pigs as a recombinant form of flu strains
from birds and humans. This outbreak confirmed that pigs can serve as a
crucible where novel influenza viruses emerge as a result of the reassortment
of genes from different strains. Genetic components of these 1998 triple-
hybrid stains would later form six out of the eight viral gene segment in the
2009 flu outbreak.
2007 Philippine outbreak in swine
On August 20, 2007 Department of Agriculture officers investigated the
outbreak (epizootic) of swine flu in Nueva Ecija and Central Luzon,
Philippines. The mortality rate is less than 10% for swine flu, unless there
are complications like hog cholera. On July 27, 2007, the Philippine
National Meat Inspection Service (NMIS) raised a hog cholera "red alert"
warning over Metro Manila and 5 regions of Luzon after the disease spread
to backyard pig farms in Bulacan and Pampanga, even if these tested
negative for the swine flu virus.
2009 outbreak in humans
The H1N1 viral strain implicated in the 2009 flu pandemic among humans
often is called "swine flu" because initial testing showed many of the genes
in the virus were similar to influenza viruses normally occurring in North
American swine. Further research has shown that three-quarters or six out of
the eight gene segments of the 2009 virus arose from the 1998 North
American swine flu strains which emerged from the first-ever reported
triple-hybrid virus of 1998.
In late April, Margaret Chan, the World Health Organization's director-
general, declared a "public health emergency of international concern" under
the rules of the WHO's new International Health Regulations when the first
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cases of the H1N1 virus were reported in the United States. Following the
outbreak, on May 2, 2009, it was reported in pigs at a farm in Alberta,
Canada, with a link to the outbreak in Mexico. The pigs are suspected to
have caught this new strain of virus from a farm worker who recently
returned from Mexico, then showed symptoms of an influenza-like illness.
These are probable cases, pending confirmation by laboratory testing.
The new strain was initially described as an apparent reassortment of at least
four strains of influenza A virus subtype H1N1, including one strain
endemic in humans, one endemic in birds, and two endemic in swine.
Subsequent analysis suggested it was a reassortment of just two strains, both
found in swine. Although initial reports identified the new strain as swine
influenza (i.e., a zoonosis originating in swine), its genetic origin was only
later revealed to have been mostly a descendant of the triple-reassortment
virus which emerged in factory farms in the United States in 1998. Several
countries took precautionary measures to reduce the chances for a global
pandemic of the disease. The 2009 swine flu has been compared to other
similar types of influenza virus in terms of mortality: "in the US it appears
that for every 1000 people who get infected, about 40 people need admission
to hospital and about one person dies." There are fears that swine flu will
become a major global pandemic at the end of the year (coinciding with the
Northern Hemisphere winter months), with many countries planning major
vaccination campaigns.
Transmission
Transmission between pigs
Influenza is quite common in pigs, with about half of breeding pigs having
been exposed to the virus in the US. Antibodies to the virus are also
common in pigs in other countries.
The main route of transmission is through direct contact between infected
and uninfected animals. These close contacts are particularly common
during animal transport. Intensive farming may also increase the risk of
transmission, as the pigs are raised in very close proximity to each other.
The direct transfer of the virus probably occurs either by pigs touching
noses, or through dried mucus. Airborne transmission through the aerosols
produced by pigs coughing or sneezing are also an important means of
infection. The virus usually spreads quickly through a herd, infecting all the
pigs within just a few days. Transmission may also occur through wild
animals, such as wild boar, which can spread the disease between farms.
Transmission to humans

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People who work with poultry and swine, especially people with intense
exposures, are at increased risk of zoonotic infection with influenza virus
endemic in these animals, and constitute a population of human hosts in
which zoonosis and reassortment can co-occur. Vaccination of these workers
against influenza and surveillance for new influenza strains among this
population may therefore be an important public health measure.
Transmission of influenza from swine to humans who work with swine was
documented in a small surveillance study performed in 2004 at the
University of Iowa. This study among others forms the basis of a
recommendation that people whose jobs involve handling poultry and swine
be the focus of increased public health surveillance. Other professions at
particular risk of infection are veterinarians and meat processing workers,
although the risk of infection for both of these groups is lower than that of
farm workers.
Interaction with avian H5N1 in pigs
Pigs are unusual as they can be infected with influenza strains that usually
infect three different species: pigs, birds and humans. This makes pigs a host
where influenza viruses might exchange genes, producing new and
dangerous strains. Avian influenza virus H3N2 is endemic in pigs in China
and has been detected in pigs in Vietnam, increasing fears of the emergence
of new variant strains. H3N2 evolved from H2N2 by antigenic shift. In
August 2004, researchers in China found H5N1 in pigs.

These H5N1 infections may be quite common: in a survey of 10 apparently

healthy pigs housed near poultry farms in West Java, where avian flu had
broken out, five of the pig samples contained the H5N1 virus. The
Indonesian government has since found similar results in the same region.
Additional tests of 150 pigs outside the area were negative.
Signs and symptoms
In swine
In pigs influenza infection produces fever, lethargy, sneezing, coughing,
difficulty breathing and decreased appetite. In some cases the infection can
cause abortion. Although mortality is usually low (around 1–4%), the virus
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can produce weight loss and poor growth, causing economic loss to farmers.
Infected pigs can lose up to 12 pounds of body weight over a 3 to 4 week
period.
In humans

Main symptoms of swine flu in humans

Direct transmission of a swine flu virus from pigs to humans is occasionally
possible (called zoonotic swine flu). In all, 50 cases are known to have
occurred since the first report in medical literature in 1958, which have
resulted in a total of six deaths. Of these six people, one was pregnant, one
had leukemia, one had Hodgkin disease and two were known to be
previously healthy. Despite these apparently low numbers of infections, the
true rate of infection may be higher, since most cases only cause a very mild
disease, and will probably never be reported or diagnosed.
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According to the Centers for Disease Control and Prevention (CDC), in
humans the symptoms of the 2009 "swine flu" H1N1 virus are similar to
those of influenza and of influenza-like illness in general. Symptoms include
fever, cough, sore throat, body aches, headache, chills and fatigue. The 2009
outbreak has shown an increased percentage of patients reporting diarrhea
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and vomiting. The 2009 H1N1 virus is not zoonotic swine flu, as it is not
transmitted from pigs to humans, but from person to person.
Because these symptoms are not specific to swine flu, a differential
diagnosis of probable swine flu requires not only symptoms but also a high
likelihood of swine flu due to the person's recent history. For example,
during the 2009 swine flu outbreak in the United States, CDC advised
physicians to "consider swine influenza infection in the differential
diagnosis of patients with acute febrile respiratory illness who have either
been in contact with persons with confirmed swine flu, or who were in one
of the five U.S. states that have reported swine flu cases or in Mexico during
the 7 days preceding their illness onset." A diagnosis of confirmed swine flu
requires laboratory testing of a respiratory sample (a simple nose and throat
swab).
The most common cause of death is respiratory failure. Other causes of
death are pneumonia (leading to sepsis), high fever (leading to neurological
problems), dehydration (from excessive vomiting and diarrhea) and
electrolyte imbalance. Fatalities are more likely in young children and the
elderly.
Diagnosis
Different medical kits are available for diagnosis of swine flu.
The two major tests that are being used are the nasopharyngeal (or back of
the throat) swab for viral culture, the gold standard, and the indirect
evidence test by detection of antibodies to novel H1N1 with PCR studies.
Prevention
Prevention of swine influenza has three components: prevention in swine,
prevention of transmission to humans, and prevention of its spread among
humans.
In swine
Methods of preventing the spread of influenza among swine include facility
management, herd management, and vaccination (ATCvet code:
QI09AA03). Because much of the illness and death associated with swine
flu involves secondary infection by other pathogens, control strategies that
rely on vaccination may be insufficient.
Control of swine influenza by vaccination has become more difficult in
recent decades, as the evolution of the virus has resulted in inconsistent
responses to traditional vaccines. Standard commercial swine flu vaccines
are effective in controlling the infection when the virus strains match enough
to have significant cross-protection, and custom (autogenous) vaccines made
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from the specific viruses isolated are created and used in the more difficult
cases. Present vaccination strategies for SIV control and prevention in swine
farms typically include the use of one of several bivalent SIV vaccines
commercially available in the United States. Of the 97 recent H3N2 isolates
examined, only 41 isolates had strong serologic cross-reactions with
antiserum to three commercial SIV vaccines. Since the protective ability of
influenza vaccines depends primarily on the closeness of the match between
the vaccine virus and the epidemic virus, the presence of nonreactive H3N2
SIV variants suggests that current commercial vaccines might not effectively
protect pigs from infection with a majority of H3N2 viruses. The United
States Department of Agriculture researchers say that while pig vaccination
keeps pigs from getting sick, it does not block infection or shedding of the
virus.
Facility management includes using disinfectants and ambient temperature
to control virus in the environment. The virus is unlikely to survive outside
living cells for more than two weeks, except in cold (but above freezing)
conditions, and it is readily inactivated by disinfectants. Herd management
includes not adding pigs carrying influenza to herds that have not been
exposed to the virus. The virus survives in healthy carrier pigs for up to 3
months and can be recovered from them between outbreaks. Carrier pigs are
usually responsible for the introduction of SIV into previously uninfected
herds and countries, so new animals should be quarantined. After an
outbreak, as immunity in exposed pigs wanes, new outbreaks of the same
strain can occur.

In humans

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Swine can be infected by both avian and human influenza strains of
influenza, and therefore are hosts where the antigenic shifts can occur that
create new influenza strains.
The transmission from swine to human is believed to occur mainly in swine
farms where farmers are in close contact with live pigs. Although strains of
swine influenza are usually not able to infect humans this may occasionally
happen, so farmers and veterinarians are encouraged to use a face mask
when dealing with infected animals. The use of vaccines on swine to prevent
their infection is a major method of limiting swine to human transmission.
Risk factors that may contribute to swine-to-human transmission include
smoking and not wearing gloves when working with sick animals.
Prevention of human to human transmission
Influenza spreads between humans through coughing or sneezing and people
touching something with the virus on it and then touching their own nose or
mouth. Swine flu cannot be spread by pork products, since the virus is not
transmitted through food. The swine flu in humans is most contagious
during the first five days of the illness although some people, most
commonly children, can remain contagious for up to ten days. Diagnosis can
be made by sending a specimen, collected during the first five days for
analysis.

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Thermal imaging camera & screen, photographed in an airport terminal in
Greece. Thermal imaging can detect elevated body temperature, one of the
signs of the virus N1H1 (Swine influenza).
Recommendations to prevent spread of the virus among humans include
using standard infection control against influenza. This includes frequent
washing of hands with soap and water or with alcohol-based hand sanitizers,
especially after being out in public. Chance of transmission is also reduced
by disinfecting household surfaces, which can be done effectively with a
diluted chlorine bleach solution.
Experts agree that hand-washing can help prevent viral infections, including
ordinary influenza and the swine flu virus. Also avoiding touching eyes,
nose and mouth with hands prevents flu. Influenza can spread in coughs or
sneezes, but an increasing body of evidence shows small droplets containing
the virus can linger on tabletops, telephones and other surfaces and be
transferred via the fingers to the mouth, nose or eyes. Alcohol-based gel or
foam hand sanitizers work well to destroy viruses and bacteria. Anyone with
flu-like symptoms such as a sudden fever, cough or muscle aches should
stay away from work or public transportation and should contact a doctor for
advice.
Social distancing is another tactic. It means staying away from other people
who might be infected and can include avoiding large gatherings, spreading
out a little at work, or perhaps staying home and lying low if an infection is
spreading in a community. Public health and other responsible authorities
have action plans which may request or require social distancing actions
depending on the severity of the outbreak.
Vaccination
Vaccines are available for different kinds of swine flu. Although the current
trivalent influenza vaccine is unlikely to provide protection against the new
2009 H1N1 strain, vaccines against the new strain are being developed and
could be ready as early as November 2009.

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Treatment
In swine
As swine influenza is rarely fatal to pigs, little treatment beyond rest and
supportive care is required. Instead veterinary efforts are focused on
preventing the spread of the virus throughout the farm, or to other farms.
Vaccination and animal management techniques are most important in these
efforts. Antibiotics are also used to treat this disease, which although they
have no effect against the influenza virus, do help prevent bacterial
pneumonia and other secondary infections in influenza-weakened herds.
In humans
If a person becomes sick with swine flu, antiviral drugs can make the illness
milder and make the patient feel better faster. They may also prevent serious
flu complications. For treatment, antiviral drugs work best if started soon
after getting sick (within 2 days of symptoms). Beside antivirals, supportive
care at home or in hospital, focuses on controlling fevers, relieving pain and
maintaining fluid balance, as well as identifying and treating any secondary
infections or other medical problems. The U.S. Centers for Disease Control
and Prevention recommends the use of Tamiflu (oseltamivir) or Relenza
(zanamivir) for the treatment and/or prevention of infection with swine
influenza viruses; however, the majority of people infected with the virus
make a full recovery without requiring medical attention or antiviral drugs.
The virus isolates in the 2009 outbreak have been found resistant to
amantadine and rimantadine.
In the U.S., on April 27, 2009, the Food and Drug Administration (FDA)
issued Emergency Use Authorizations to make available Relenza and
Tamiflu antiviral drugs to treat the swine influenza virus in cases for which
they are currently unapproved. The agency issued these EUAs to allow
treatment of patients younger than the current approval allows and to allow
the widespread distribution of the drugs, including by non-licensed
volunteers.

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